Portacaval anastomosis (PCA) has been the standard treatment of patients who have bled from varices for more than 25 years. Recent controlled investigations of PCA have shown that although this operation has virtually eliminated hemorrhage from varices, it failed to improve survival significantly. In effect it substituted deaths from hepatic failure and portal-systemic encephalopathy (PSE) for death from hemorrhage. It has been postulated that post-shunt hepatic failure and PSE result from deprivation of hepatotrophic substances in the portal blood. Warren et al devised the distal splenorenal shunt (DSRS) to decompress varices without interrupting portal blood flow to the liver. Preliminary reports indicate that DSRS, although more difficult and of higher operative mortality than PCA, prevents further bleeding without inducing PSE. In 1975 we undertook a controlled, randomized investigation comparing PCA and DSRS in patients who have survived variceal hemorrhage jointly with our associates at Yale University. In the past 33 months we have operated on 28 patients, and the operative mortality and occurrence of PSE in the two groups is similar. We propose to continue this study for 4 years to achieve a total of 80 randomized patients. In the course of this study we propose to compare prospectively the frequency and pathogenesis of a number of "complications" of portacaval anastomosis that have been attributed to portal-systemic shunting and from deprivation of portal blood flow. These include 1) PSE, 2) post-shunt hepatic failure, 3) peptic ulcer disease, 4) hemosiderosis, 5) diabetes. In addition, we will compare the effects of these two operations on hypersplenism and will compare objectively methods for the assessment of shunt patency.